Introduction: The uses of general anesthesia in outpatient invasive procedures have increased, especially in dermatology. Being uncooperative, children often require general anesthesia since surgical skin operations are mostly painful. Purpose: The aim of this study is to evaluate the safety, significant adverse events, and the complication rates related to general anesthesia when used among pediatric population underwent skin procedures. Methods: A retrospective cohort study of a patient chart review from the period (September 1, 2017, to September 2019). All patients admitted for pediatric skin procedures during this period have participated in our study. We reviewed selected charts to document any unexpected admissions, adverse events, or complications. Surgical outcomes and anesthesia complications were reviewed by three anesthesiologists. We assessed inter-rater reliability. Results: A total of 211 procedures were reported for 211 patients with 19 diagnoses. No adverse events related to anesthesia were recognized, apart from minor complications noticed in 12 patients. Kappa value ranges between 0.78 and 1.00 (95% confidence interval, 0.46809–1.00). Conclusion: Dermatologists and pediatricians can safely do necessary procedures under general anesthesia with the supervision of pediatric-trained anesthesiologists while considering other safety and risk precautions and pediatric age group.

Surgical skin procedures are usually done as an outpatient service and accompanied by a few trivial complications.[1] A multicenter retrospective review found no serious complications among pediatric patients.[1] Recently, the use of general anesthesia in pediatric skin procedures has increased.[2]

It is challenging to mollify a conscious child during an invasive procedure even with local anesthesia. Surgeons often have to operate young children using general anesthesia to minimize pain and psychological trauma associated with local anesthesia and also to improve the overall outcome.[1] Randomized control trials evaluating general anesthesia in pediatric invasive skin procedures in comparison with local anesthesia or any other approach are sparse. We conducted this retrospective cohort study to assess the safety of general anesthesia in the pediatric population undergoing dermatologic procedures.[3]

Materials and Methods

Patients were identified through electronic medical records of a tertiary care hospital. Patients who had surgeries under general anesthesia done by dermatologists from the period September 1, 2017, to September 2019 were included in the study. An adverse event was defined as any complication related to the general anesthesia during the operation or immediately postoperative or an unplanned readmission within 1 week of the operation due to a cause related to anesthesia either to the clinic or pediatric emergency department. Substantial adverse events were described as any complication which leads to undesirable outcomes or medical intervention leading to the extended length of stay. We conducted a retrospective file review to gather patients' demographic criteria such as age, gender, diagnosis and performed procedures, and unexpected admissions, incidents, or complications. We obtained the approval from the Institutional Review Board.

All the patients had an American Society of Anesthesiologists Status I or II. A pediatric anesthesiologist administered the general anesthesia to all patients. All patients were provided strict instructions prohibiting them to eat or drink anything, 2 h before the procedure, unless being an infant <5 months old, in which case only clear fluids were allowed. Easily digestible solids were not allowed 4–6 h before surgery. Milk products were not allowed 8 h before the surgery. We used nitrous oxide, oxygen, and sevofluorane for anesthesia induction and maintenance. We frequently administered other agents during the procedure, including ondansetron, ketorolac, and dolasetron. Morphine or fentanyl was also given. Midazolam and acetaminophen, solo or in combination with codeine, were also administered occasionally as premedication. Marcaine 0.25% was locally infiltrated around the surgical incision in case of excision-repair procedures. We gave our patients morphine or fentanyl postoperatively for pain control if required. Ibuprofen or acetaminophen was prescribed as home medication on discharge for pain control if necessary.

Postoperative complication severity was classified as minor or major and was assessed by three pediatric anesthesia consultants to reach a consensus about the level of severity. Each anesthesiologist evaluated the postoperative complication against prespecified criteria[4] and gave a score from 1 to 5 (Likert scale). “One” was interpreted as strongly disagree and “five” as strongly agree.

We conducted inter-rater reliability (IRR) tests to determine the level of agreement between the raters. We also used the intraclass correlation and measured the consistency of ratings because we have more than two raters. The inter-rater agreement was appraised by calculating the “Fleiss' kappa statistic” for each contributor.[5] The estimation of the statistic was established to be 1.00 when there was comprehensive agreement and “zero” when the rate was alike to that perceived by chance [Table 1]. The level of agreement among raters' Likert scale scores was assessed by the IRR tests and determination of intraclass correlation coefficient (kappa value).

The correlation between contributors' responses was analyzed with the “Chi-square nonparametric test”, with a level of significance of 5%, with a 95% confidence interval (CI). The analyses were all prespecified, including the calculation of the minimum “n” and the “factor beta” statistical error, which was lower than 20%.

We performed statistical analyses with IBM-SPSS “version 20” software (IBM Corp, Armonk, NY, USA). Descriptive data were described. Based on the kappa correlation coefficient, the results were categorized as “excellent, very good, good, moderate, fair, and poor.”

Results

A total of 211 procedures under general anesthesia were performed on 211 unique pediatric patients with a total of 19 dermatological diagnoses. The patients' age ranged from 4 months to 17 years of age, with a mean age of 4.7 years. A total of 111 (52.6%) patients were males and 100 (47.3%) were females [Table 2].

A total of 12 of the 211 patients (5.6%) had clinically relevant complications related to anesthesia [Table 4], of whom four patients developed postoperative sore throat, nausea, and vomiting. Three patients developed a mild-to-moderate postoperative frontal headache. Two patients developed postoperative minor trauma to the teeth and lips. One patient developed postoperative “Bruising” from intravenous injection. One patient developed postoperative painful neck muscles.

One patient experienced recall of unpleasant dreams and return to consciousness before completion of pharyngeal suction and extubating. No vascular complications such as thrombosis or thrombophlebitis were noted. No nerve complications arise from malpositioning of the patient on the operating table. No eye complications such as corneal abrasions were identified. There was no immediate intra- or postoperative complication such as bradycardia, tachycardia, and apnea in our patient population. No admissions for dehydration from nausea and vomiting were recorded.

Three pediatric anesthesiologists evaluated the 12 patients with complications [Table 5]. All the 12 patients had minor complications related to anesthesia. IRR was high for every question in the evaluation criteria and for every patient. Most of the kappa values were between 0.70 and 1.00 (95% CI, 0.46809–1.00) denoting very good to excellent agreement [Figure 1] and [Figure 2].

Table 5: Prespecified adopted criteria against which the complications were evaluated

The safety of pediatric general anesthesia has been addressed up to the present.[6] However, recent epidemiological researches concerning general anesthesia-related complications, particularly in pediatric skin surgeries, were scarce.[7] The available literature is mostly on general anesthesia in major operations such as neurosurgery, cardiovascular surgery, and abdominal surgery in adults and children.[8] Few articles have addressed the safety of general anesthesia in pediatric dermatology. Morbidity and mortality from general anesthesia in skin surgeries among children are very rare and clinically insignificant.[6],[9]

The incidence of postoperative headache as a minor complication related to anesthesia ranges between 2% and 70%.[10] Substantial reasons for this wide range are not apparent.[11] However, short-lived or mild headache may go unreported by a patient or observer.[12] Our results showed a low incidence of headache in spite of patient interviewing. No serious complications or mortalities were noted.

The findings of our study are consistent with previous publications. The complications of general anesthesia after elective pediatric dermatologic operations were very low, as shown in a multicenter study that was done to evaluate the safety and adverse events of general anesthesia which included 270 children between 2 months and 18 years old.[1]

Another study found that laryngospasm and transient apnea were the most common complications noted; however, the results were statistically insignificant.[13] Our findings did not show any incidents of laryngospasm or apnea. Wound infection was a common complication after skin surgeries; however, these infections are not related to anesthesia.[14]

General anesthesia is safe and appropriate for different pediatric dermatologic operations, regardless of age.[15] Timely surgical intervention under general anesthesia may be the best option in children with lesions that are associated with substantial health risks or may result in deformity or functional impairment if left untreated,[16] in children who will benefit from early surgical intervention because of the superior cosmetic outcome which will be obtained,[17] as well as in children where the timely surgical correction will positively affect their psychosocial status and self-esteem.[18] Deep sedation and general anesthesia are safe and cost-effective approaches to control pain. Physicians should consider encouraging parents to do such procedures as early as possible.[19]

Before the use of general anesthesia, many concerns are routinely addressed, such as the health of the patient, appropriate choice of surgery, expected outcome, benefits of early surgical intervention in children, and right anesthesia setting.[9] To avoid postoperative complications such as large scaring, spread scar, or wound dehiscence, surgeons should consider an early intervention at a young age. The skin is elastic, redundant with less muscle mass. This allows easily usage of skin flaps, tissue expanders, or grafts. Lesion at a young age is not under big tension.[11],[15],[20]

In children, sedation is more risky than in adults because sedation levels are not as obviously distinct.[21] Sedation also does not provide characteristic airway protection in comparison to general anesthesia.[22] Repair procedures and large excisions are too painful to be controlled by light sedation. Moreover, even small excision with little pain is difficult to be controlled by light sedation because of the fear of uncooperative behavior of the child.[23] Death of children has occurred because the anesthesiologists failed to save the airway in spite of safe sedation.[24]

It can be difficult to secure the airway during the procedure done under sedation.[25] Children have compromised airways due to anatomical variation that makes their airway more prone to obstruction or injury. In addition to the relatively large tongue and small oral cavity which make the procedure of accurate evaluation difficult. Other factors that make the process of airway protection in children impossible include prominent laryngeal and pharyngeal structures, short trachea, and neck flexion due to projecting occipital bulge.[26]

Sedation may be valuable in case of minor procedures with short duration provided that there is an adequate number of well-trained personnel and equipment to ensure the safety and proper management of the airway.[27] On the other hand, general anesthesia can be considered for excision and repair. Generally, the usage of general anesthesia in pediatric surgeries is favorable and safer than sedation.[28]

Trained anesthesiologists ensure the proper position of the endotracheal tube by proper positioning of the patient's head to avoid displacement of the tube into the right bronchus or dislodgment. Trained staff, beside their experience of at least 250 pediatric performed cases per year, have a lower incidence of anesthesia-related complications compared with children treated by nontrained anesthesiologists.[16] Associated comorbidities, prolonged procedures, and lack of trained staff increased the anesthesia-related complications by 300%.[16] The usage of the fast-acting anesthetic agent by inhalation was associated with a lower risk of general anesthesia.[18]

Conclusion

In conclusion, with proper staff, appropriate surgical procedure, patient selection, and modern technology, dermatologists and pediatricians can safely do necessary procedures under general anesthesia with the supervision of pediatric-trained anesthesiologists.

Acknowledgment

We would like to thank the Deanship of Scientific Research, Research Chairs at King Saud University, for funding this study.

Cote J, Wilson S, the Work Group on Sedation. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics 2006;118:2587–602.

American Academy of Pediatrics, American Academy of Pediatric Dentistry, Coté CJ, Wilson S; Work Group on Sedation. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: An update. Pediatrics 2006;118:2587-602.